<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Department_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-department_id" data-rule="required" data-source="dicts\Department\getDepartmentList222"
                data-field="department" class="form-control selectpage" name="row[department_id]" type="text"
                value="{$row.department_id|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Operator')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-operator" readonly="readonly" data-rule="required" class="form-control" name="row[operator]"
                type="text" value="{$operator|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Actual_bed_days')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-actual_bed_days" data-rule="required" min="0" class="form-control" name="row[actual_bed_days]"
                type="number" value="{$row.actual_bed_days|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('New_admissions_count')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-new_admissions_count" data-rule="required" min="0" class="form-control"
                name="row[new_admissions_count]" type="number" value="{$row.new_admissions_count|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Day_shift_nurses')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-day_shift_nurses" data-rule="required" min="0" class="form-control"
                name="row[day_shift_nurses]" type="number" value="{$row.day_shift_nurses|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Day_shift_patients')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-day_shift_patients" data-rule="required" min="0" class="form-control"
                name="row[day_shift_patients]" type="number" value="{$row.day_shift_patients|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Night_shift_nurses')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-night_shift_nurses" data-rule="required" class="form-control" name="row[night_shift_nurses]"
                type="number" value="{$row.night_shift_nurses|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Night_shift_patients')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-night_shift_patients" data-rule="required" class="form-control"
                name="row[night_shift_patients]" type="number" value="{$row.night_shift_patients|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Nurse_work_hours')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-nurse_work_hours" data-rule="required" class="form-control" name="row[nurse_work_hours]"
                type="number" value="{$row.nurse_work_hours|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Catheter_days')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-catheter_days" data-rule="required" class="form-control" name="row[catheter_days]"
                type="number" value="{$row.catheter_days|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Astro_tube_days')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-astro_tube_days" data-rule="required" class="form-control" name="row[astro_tube_days]"
                type="number" value="{$row.astro_tube_days|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Trachea_tube_days')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-trachea_tube_days" data-rule="required" class="form-control" name="row[trachea_tube_days]"
                type="number" value="{$row.trachea_tube_days|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Cvc_days')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-cvc_days" data-rule="required" class="form-control" name="row[cvc_days]" type="number"
                value="{$row.cvc_days|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Picc_days')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-picc_days" data-rule="required" class="form-control" name="row[picc_days]" type="number"
                value="{$row.picc_days|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Restraint_days')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-restraint_days" data-rule="required" class="form-control" name="row[restraint_days]"
                type="number" value="{$row.restraint_days|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Special_care_bed_days')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-special_care_bed_days" data-rule="required" class="form-control"
                name="row[special_care_bed_days]" type="number" value="{$row.special_care_bed_days|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Level_1_bed_days')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-level_1_bed_days" data-rule="required" class="form-control" name="row[level_1_bed_days]"
                type="number" value="{$row.level_1_bed_days|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Level_2_bed_days')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-level_2_bed_days" data-rule="required" class="form-control" name="row[level_2_bed_days]"
                type="number" value="{$row.level_2_bed_days|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Level_3_bed_days')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-level_3_bed_days" data-rule="required" class="form-control" name="row[level_3_bed_days]"
                type="number" value="{$row.level_3_bed_days|htmlentities}">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-primary btn-embossed disabled">{:__('OK')}</button>
        </div>
    </div>
</form>